Disease X mentioned several times by the WHO a few days ago, it can be a known new crown virus, an influenza virus, or an unknown disease. For example, the recent outbreak of streptococcal toxic shock syndrome (STSS) in Japan has raised concerns about whether the bacterium will sweep the world like the new coronavirus. In the first two months of 2024, 378 cases of streptococcal toxic shock syndrome (STSS) were recorded in Japan, and only two of Japan's 47 prefectures had no confirmed cases. On April 3, the Hong Kong Department of Health said that a Hong Kong citizen died in Japan due to necrotizing fasciitis (known as "flesh-eating fungus infection" in Japan, Hong Kong and Macau) caused by Streptococcus A. Domestic doctors have also found some children with streptococcal infection. Two days ago, I wrote about the prevention of group A streptococcal infection, and today I will talk about what symptoms are after infection and how doctors will treat them.
▍Streptococcal toxic shock syndrome, what is it? [1]
Streptococcal toxic shock syndrome (STSS) is an acute infection caused by a specific type of streptococcus, often group A β hemolytic streptococcus.
It is important to note that medical terminology sometimes varies from region to region or from literature to literature, but refers to the same bacteria.
A组β溶血性链球菌（Group A Streptococcus，简称GAS），又叫A族链球菌、A组链球菌，也叫化脓性链球菌。
Group A β hemolytic streptococci belongs to the genus Streptococcus. The bacteria can cause a wide range of human diseases, ranging from mild illnesses such as tonsillar inflammation, pharyngitis, impetigo, cellulitis, and scarlet fever to severe invasive diseases such as gangrene or sepsis [4-6].
This infection progresses particularly quickly, leading to multiple organ failure in a short period of time. The main symptoms are high fever, low blood pressure (shock), multi-organ dysfunction, and a rash that may occur.
In recent years, the increase in invasive group A streptococcal infections has caused serious problems in many countries around the world, among which streptococcal toxic shock syndrome and necrotizing fasciitis are the most serious types of invasive group A streptococcal infections, with a case fatality rate of 20%~45% despite antimicrobial and supportive care [2,3].
Because it is similar to other forms of septic shock, the symptoms are not specific, the progression is rapid and fatal, and some cases are not diagnosed even after the patient's death, and medical malpractice is often suspected [4]
So far this year, 40 people in Nova Scotia, Canada, have been infected with invasive group A streptococcus (GAS), and 6-year-old Jaydon Davis has died of infection with invasive group A streptococcus. Randy Davis, the child's father, said, "We found out too late and this thing (streptococcus) deteriorated too quickly. ”
On March 3 (Sunday), the child had a low-grade fever, but he was able to play with his sister and had a good appetite at dinner at night, so the parents were not too worried. The next morning, the child appeared to be in good health and went to school, but came home with a fever.
Until this time, the child's symptoms were no different from ordinary fever. By Tuesday, he started vomiting, sweating, shivering, and his body temperature rose significantly. The child's father said they didn't have a family doctor, so they booked an online medical consultation. After listening to the child's cough, the doctor prescribed an inhaled medicine for him. However, on March 6, within 48 hours of the onset of symptoms, the child passed away [7-8].
▍What are the symptoms in the early and middle and late stages? [1,5]
Early symptoms
Usually a day or two before hypotension occurs, some common symptoms appear. For example, fever, feeling cold, diarrhea, headache, sore throat, muscle pain, and even feeling unclear or very sleepy.
Fever was the most common symptom (89%), followed by gastrointestinal upset (67%), shortness of breath (56%), and cellulitis (33%).
注：蜂窝织炎（cellulitis）是指皮肤和皮下组织的化脓性感染。
Some erythema will also appear on the skin in the early stages, especially on the upper chest, and some people will also have wounds on the skin, which may be where the germs invade. These wounds may be swollen or bleeding, sometimes seem less noticeable, or may have crusted over, so your doctor will need to look for them carefully when examining them.
Symptoms may also occur on the mucous membranes, such as conjunctival hyperemia in the eye, vaginitis, or in the mouth (bayberry tongue).
This syndrome should be considered if your child's skin and soft tissues are erythematous, hard and swollen, and they have a fever all the time.
It is important to note that the site of the infection is particularly painful, and this pain is related to the soft tissue inflammation of the streptococcal infection, so it is generally much more painful than the wound seems.
If the pain is greater than expected during the doctor's examination, especially if blisters or ecchymoses like purpura appear on the skin, it is important to consider necrotizing fasciitis, which is associated with severe streptococcal syndrome.
Moderate and late stage symptoms
On top of the early symptoms, the condition deteriorates rapidly, breathing and heartbeat are rapid, typical symptoms of shock may appear, and multiple organs begin to fail.
If the condition is very serious, even if you do your best to save and treat them, you may die within a day or two of being hospitalized. However, if the patient survives, within 1-3 weeks of the onset of the disease, a purpura-like rash may appear, and the palms and soles of the feet may begin to peel, as if gloves and socks were taken off.
Yimaitong Health Care Club was established!
<加入社群、获得帮助、相互支持>
Join a disease cluster
(1) At present, there are patient groups: diabetes group, cardiovascular health group, Bao Ma parenting group, sub-health group, tumor patient group, mental health group;
(2) Public welfare activities in the group include: Q&A with specialists, dietary guidance from dietitians, free online consultations, and daily health science updates;
Protect your health together with Yimaitong, welcome you to join!
▍Streptococcal toxic shock syndrome, how to treat it? [1,9]
The key to reducing the occurrence and mortality of streptococcal toxic shock syndrome (STSS) is to detect it early, use appropriate antibiotics immediately, treat the infected area quickly, maintain normal blood circulation in the body, treat anti-shock treatment, protect the heart and other vital organs, and replenish the body with fluids in time.
Clindamycin + β-lactams
Before figuring out what bacteria are and which drugs they are resistant to, doctors usually prescribe one or more antibiotics to ensure that they cover all possible pathogens.
There is now expert consensus that clindamycin should be used in combination with β-lactams (penicillin and its derivatives, cephalosporins, monoamide rings, carbapenems, and penicillemase inhibitors, etc.). Once an infection is detected, it is best to start these antibiotics intravenously within 1 hour.
According to the results of the 2020 CHINET China Antimicrobial Resistance Surveillance, group A β hemolytic streptococci were resistant to erythromycin and clindamycin, with a resistance rate of 88.3% to erythromycin and a resistance rate of 86.7% to clindamycin.
However, clindamycin is still used in combination therapy because it can prevent the production of certain super toxins, enter the body more easily than penicillin, and have a stronger sustained antibacterial effect, which can improve survival.
However, when your child's temperature is normal, symptoms improve, and there are no signs of streptococcal toxic shock syndrome, clindamycin should be stopped.
Surgical debridement
However, it is important to note that antibiotics have a weak ability to enter infected tissues, soft tissues, or dead muscle parts, and antibiotics alone are not enough, and surgical procedures are also needed to deal with infected and dead tissues.
For example, in necrotizing fasciitis, early surgery is important, and sometimes multiple debridements may be required, or even amputation is necessary to save life.
Intravenous gamma globulin (IVIG)
It can neutralize the toxins released by bacteria and reduce the release of cytokines, shortening the course of the disease. Although its efficacy is not fully established, a retrospective cohort study of pediatric ICUs in the United States suggests that intravenous gamma globulin is commonly used in the treatment of severe cases in pediatric ICUs, such as for certain toxic shocks and other conditions.
There is also a foreign meta-analysis that shows that it can significantly reduce mortality, and it is still worth considering as an adjuvant treatment.
Given the high mortality rate of the disease, especially if fluid resuscitation, surgery, antibiotics, and other treatments do not improve quickly, doctors generally recommend adjunctive treatment with intravenous gamma globulin.
In addition, a domestic study also found that the timely use of fast-acting β-lactam antibiotics such as penicillin, combined with the adjuvant treatment of clindamycin and human immunoglobulin, can significantly improve the effective rate of treatment of streptococcal toxic shock syndrome.
→ Star Yimaitong Health Care Center, learn some medical knowledge every day, accumulate over time, accumulate sand into a tower, and better take care of the health of yourself and your family. If you have any health-related questions, you can always consult a medical online doctor. Click on the applet below to get a doctor's answer! The consultation can cover the entire recovery process of the disease, which is equivalent to having a caring and reliable family doctor by your side. You can ask questions as many times as you want to get evidence-based answers from your doctor. References
1. Ma Yaoling, He Yanxia. Streptococcal toxic shock syndrome [J] . Chinese Journal of Practical Clinical Pediatrics, 2022, 37(21) : 1633-1636. DOI: 10.3760/cma.j.cn101070-20220806-00945.
2.NanduriSA, OnukwubeJ, ApostolM，et al. Challenges in surveillance for streptococcal toxic shock syndrome：active bacterial core survei－llance，United States，2014-2017[J]．Public Health Rep，2022，137(4)：687-694. DOI：10.1177/00333549211013460.3.YamabaY, TakakuwaO, IdaC，et al. Streptococcal toxic shock syndrome induced by group a streptococcus with the emm28 genotype that deve－loped after a uterine cancer test[J]．Intern Med，2021，60(21)：3481-3483. DOI：10.2169/internalmedicine.6290-20.4.Steer AC, Law I, Matatolu L, Beall BW, Carapetis JR. Global emm type distribution of group A streptococci: systematic review and implications for vaccine development. Lancet Infect Dis. 2009 Oct; 9(10):611-6. doi: 10.1016/S1473-3099(09)70178-1. PMID: 19778762.5.Cunningham MW. Pathogenesis of group A streptococcal infections. Clin Microbiol Rev. 2000 Jul; 13(3):470-511. doi: 10.1128/CMR.13.3.470-511.2000. PMID: 10885988; PMCID: PMC88939.6.Carapetis JR, Steer AC, Mulholland EK, Weber M. The global burden of group A streptococcal diseases. Lancet Infect Dis. 2005 Nov; 5(11):685-94. doi: 10.1016/S1473-3099(05)70267-X. PMID: 162538867.Nova Scotia child dies from aggressive form of strep, family speaks outBy Skye Bryden-Blom Global NewsPosted March 18, 2024 5:32 pm Updated March 18, 2024 8. 一名6岁男童发烧3天后悄然去世，病毒发展得太快，事发时家人甚至没有反应过来！美国妈妈网 2024-03-269.Zhang HX, Dong J, Huang JT, Zhang KY, Lu XL, Zhao X, Xiao CQ. 32例儿童链球菌中毒性休克综合征药物治疗疗效分析 [Drug treatment efficacy in 32 children with streptococcal toxic shock syndrome]. Zhongguo Dang Dai Er Ke Za Zhi. 2023 Sept 15; 25(9):971-975. Chinese. doi: 10.7499/j.issn.1008-8830.2306030. PMID: 37718405; PMCID: PMC10511230.
Tips: Popular science articles do not provide professional diagnosis and treatment opinions, please carry out specific diagnosis and treatment under the guidance of professional doctors, the picture comes from Visual China